Even as the conflicts in Afghanistan and Iraq roll on, wounded servicemen and women are returning home with injuries that may require years of medical and psychological rehabilitation. Last month EyeNet featured the experiences of Thomas H. Mader, MD, Sean M. Blaydon, MD, and Mark F. Torres, MD, each of whom served on Army surgical teams close to combat zones. The soldiers they treated are now filling polytrauma facilities in the United States.

Whisked Away From War

Troops wounded in Iraq or Afghanistan undergo emergent primary repairs to life- and sight-threatening injuries often within minutes of sustaining the injury. When stable enough, they are transported several times to various levels of care.

The first stop is Landstuhl Army Medical Center in Germany, then on to Walter Reed Army Medical Center in Washington, D.C., or Brooke Army Medical Center in San Antonio, and finally on to tertiary-care hospitals around the country.

These later stages of care can be the hardest part for both doctors and patients. “It’s one thing to sew somebody up as best we could do, and it’s another thing to provide the follow-up care,” said Dr. Mader. “That is a very, very difficult job, both professionally and emotionally. As you can imagine, the psychological impact of a young man losing one or both eyes has to be dealt with by both patient and physician.”

Physicians and families take a long view. The community ophthalmologist may be seeing more such veterans, and they will need multiple levels of care for many years, according to Glenn C. Cockerham, MD, chief of ophthalmology at the VA Palo Alto Health Care System and clinical associate professor of ophthalmology at Stanford University.

“When they come to us they are entering a period in which late complications, including retinal detachments, corneal decompensation, traumatic cataracts or posterior capsular opacifications, may present,” said Dr. Cockerham. “If one eye, usually on the side of the blast, is severely damaged, it is extremely important to take special care of their better-seeing eye. But many of them have head injuries and resulting memory problems, so we include families in the rehabilitation process to watch over their loved one and make sure they get to appointments. Their families are usually very supportive, having been there for them throughout.”

Collaborative care is key. Dr. Torres explained how the community ophthalmologist can offer veterans care. “There are a lot of joint arrangements between military hospitals and the VA, and between the VA and civilian academic medical centers. The average comprehensive ophthalmologist offering long-term management of a combat-related trauma should, pretty easily, be able to consult with combat-experienced ophthalmologists.”

Dr. Blaydon agreed. “The general ophthalmologists can manage these returning vets, but they might be seeing a different trauma than they would in an emergency room. Much of it is explosive, high-velocity, blunt trauma to the face, which means there’s a lot of soft-tissue damage and underlying skeletal damage. Many had globe ruptures that were severe and complex, and there are often fine, foreign bodies embedded in the cornea. Even if the rupture is repaired perfectly, the patient remains corneally blind. Many of these will go on to corneal transplant. Some of them have bad retinal injuries from just blunt trauma.”

Courage and Candor Beyond the War

Most returning veterans are very young, between their late teens and early 20s. Dr. Blaydon maintains a deep regard for their emotional well-being. “I am in awe of the attitude and the motivation of these young guys. Before you address their specific injury, it’s important to consider the psychology of the veteran. They went over there to serve their country and to serve alongside their comrades, and they want us to respect the fact that they were doing their job when they got their injury. These patients need a lot of physical and emotional therapy to get back into society.”

Americans are deeply divided over the Iraq conflict. And yet, Dr. Blaydon has observed that the soldiers are coming home to a country that cares for them. “This war is as divisive as any we’ve had in the past. The difference now is that returning vets are receiving support from both sides of the fence. That’s an important part of welcoming these soldiers home.”

Hope for vision preempted. Conceivably, some of these soldiers could benefit from research into artificial retinas, research that has received significant funding from the Department of Energy. But Dr. Blaydon said the devastating nature of many injuries means that few of these veterans would be good artificial retina candidates. “The anterior visual camera, the optic nerve and visual pathway must all be intact for an artificial retina to be considered.” These crucial structures are obliterated in many vets.

Precautions slow to appear. One of the questions now haunting the military is whether U.S. troops were provided adequate protection for battle. Since the Afghanistan and Iraq conflicts began, Army ophthalmologists have repeatedly asked for troops to be given better eyewear. While no form of protection can eliminate all injuries, many could have been prevented or lessened in severity. In fact, Dr. Mader writes in Ophthalmology, “Polycarbonate ballistic eyewear could have prevented many, but not all of the ocular injuries we report.”1

Dr. Blaydon noted that ophthalmologists had long lobbied the Army for the type of ballistic eyewear that protects against low-velocity projectiles. The Army had developed eye armor known as Ballistic/Laser Protective Spectacles, but almost none of the soldiers had them. “The Army, as far as we could tell, did not issue them. Eye armor just was not part of the issue,” Dr. Blaydon said.

The Army did issue Sun, Wind and Dust Goggles, which can protect the eye against some minor injuries. But they are cumbersome, and can often impair clear, full peripheral vision. “Soldiers just do not like to wear them. What they do like to wear are Wiley X ballistic goggles that fit closely to the face. But the soldiers had to purchase these on their own. The Army soon realized how severe and frequent the eye injuries were and began purchasing these goggles and mandating that they be worn,” Dr. Blaydon said. Even these goggles cannot protect against the most potent improvised explosive devices, but, he noted, “The incidence of injuries has since gone down, depending on the tempo of operations.”2

From a distance. These physicians tend to deflect credit for their own heroic service into recognition of others still working in the combat zones. “Many soldiers would have died had it not been for the premier care they got in Baghdad. The surgeons there are the top-of-the-line and that care is as good as you’re going to get in a critical care hospital,” said Dr. Blaydon.

Dr. Mader regards his experience with equanimity. “If there was any positive thing about being there, I would say I worked with some of the finest young people I’ve ever met in my life. Had I been wounded and brought to that 31st Combat Support Hospital, I would have had complete faith in the medical personnel working there.”

Dr. Torres shared a similar sentiment. “It’s a rewarding experience in unfortunate circumstances. You feel like you’re doing something positive, even if the world around you is not.”

________________________________At the Joint Meeting in November, Herbert P. Fechter, MD, will moderate a panel of military ophthalmologists who will share their experiences in Afghanistan and Iraq. Photos and videos will demonstrate the special considerations of ophthalmic war surgery and will address a variety of combat-related injuries (Instruction Course #590).